Complex behavioural and educational interventions for bedwetting (nocturnal enuresis) in children

Night-time bedwetting is common in childhood, and can cause stigma, stress and inconvenience. Bed alarms are the treatments which currently appear to work best in the long term. Complex interventions such as dry bed training can also be tried. This involves, as well as using an alarm to wake the child after he or she has wet the bed, getting them to go to the toilet repeatedly and changing their own sheets. The review found 18 trials in 1174 children who had received this sort of training or another treatment. Although an alarm on its own was better than the dry bed training on its own, there was some evidence that using them together might reduce the relapse rate after stopping alarm treatment, and without the adverse effects of drug treatment. However, both using an alarm and dry bed training needs time and effort from the child and family. There was not enough research comparing complex interventions with other techniques.

Authors' conclusions: 

Although DBT and FSHT were better than no treatment when used in combination with an alarm, there was insufficient evidence to support their use without an alarm. An alarm on its own was also better than DBT on its own, but there was some evidence that combining an alarm with DBT was better than an alarm on its own, suggesting that DBT may augment the effect of an alarm. There was also some evidence that direct contact with a therapist might enhance the effects of an intervention.

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Background: 

Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15 to 20% of five-year olds, and up to 2% of young adults.

Objectives: 

To assess the effects of complex behavioural and educational interventions on nocturnal enuresis in children, and to compare them with other interventions.

Search strategy: 

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 20 March 2008) and the reference lists of relevant articles.

Selection criteria: 

All randomised or quasi-randomised trials of complex behavioural or educational interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and physical behavioural methods, alarms, desmopressin, tricyclic antidepressants, and miscellaneous other interventions.

Data collection and analysis: 

Two review authors independently assessed the quality of the eligible trials, and extracted data.

Main results: 

Eighteen trials involving 1174 children were identified which included a complex or educational intervention for nocturnal enuresis. The trials were mostly small and some had methodological problems including the use of a quasi-randomised method of concealment of allocation in three trials and baseline differences between the groups in another three.

A complex intervention (such as dry bed training (DBT) or full spectrum home training (FSHT)) including an alarm was better than no-treatment control groups (for example the relative risk (RR) for failure or relapse after stopping DBT was 0.25; 95% CI 0.16 to 0.39) but there was not enough evidence about the effects of complex interventions alone if an alarm was not used. A complex intervention on its own was not as good as an alarm on its own or the intervention supplemented by an alarm (e.g. RR for failure or relapse after DBT alone versus DBT plus alarm was 2.81; 95% CI 1.80 to 4.38). On the other hand, a complex intervention supplemented by a bed alarm might reduce the relapse rate compared with the alarm on its own (e.g. RR for failure or relapse after DBT plus alarm versus alarm alone was 0.5; 95% CI 0.31 to 0.80).

There was not enough evidence to judge whether providing educational information about enuresis was effective, irrespective of method of delivery. There was some evidence that direct contact between families and therapists enhanced the effect of a complex intervention, and that increased contact and support enhanced a package of simple behavioural interventions, but these were addressed only in single trials and the results would need to be confirmed by further randomised controlled trials, in particular the effect on use of resources.

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